What is the best course of treatment for a 41-year-old female with mild gross hematuria, dysuria, and frequency after cold exposure?

Treatment of Acute Uncomplicated Cystitis with Gross Hematuria

This 41-year-old woman has acute uncomplicated cystitis and should be treated with first-line antibiotics: either nitrofurantoin 50-100 mg four times daily for 5 days, fosfomycin trometamol 3 g single dose, or trimethoprim/sulfamethoxazole for 3 days. 1, 2

Clinical Reasoning

The presentation of dysuria, frequency, and mild gross hematuria following cold exposure in an otherwise healthy 41-year-old woman is classic for acute uncomplicated urinary tract infection (UTI). 1, 2 The cold exposure is likely coincidental rather than causative—the key diagnostic features are the lower urinary tract symptoms without systemic signs. 1

Why This is Uncomplicated Cystitis

• Self-diagnosis with typical symptoms (dysuria, frequency) in women is sufficiently accurate to diagnose uncomplicated UTI without further testing. 2
• The absence of fever, flank pain, or systemic symptoms excludes pyelonephritis. 1, 3
• At age 41 with no mentioned comorbidities, she does not meet criteria for complicated UTI. 1
• Gross hematuria is a recognized symptom of uncomplicated cystitis and does not automatically indicate complicated infection or malignancy in this age group with acute symptoms. 1, 3

No Urine Culture Required

Urine culture is unnecessary for uncomplicated cystitis in this patient. 2 Cultures should be reserved for recurrent infection, treatment failure, history of resistant organisms, or atypical presentation—none of which apply here. 1, 2

First-Line Antibiotic Options

The European Association of Urology 2024 guidelines provide clear first-line choices: 1

• Fosfomycin trometamol 3 g single dose (recommended specifically for women with uncomplicated cystitis) 1
• Nitrofurantoin macrocrystals 50-100 mg four times daily for 5 days 1
• Trimethoprim or trimethoprim/sulfamethoxazole for 3 days 1, 2

All three options have equivalent efficacy for uncomplicated cystitis. 1, 2 Selection depends on local resistance patterns, patient allergies, and cost considerations. 1

Addressing the Gross Hematuria

Why Malignancy Workup is NOT Indicated Now

The gross hematuria in this context does not require immediate urologic evaluation because it is occurring in the setting of acute infectious/inflammatory symptoms. 1, 4 The key distinguishing features are:

• Acute onset (1 day) concurrent with dysuria and frequency 1
• Age 41 with no high-risk features for malignancy (the threshold for mandatory cystoscopy is typically >40 years, but applies more to asymptomatic or isolated hematuria) 1, 4
• Clear infectious etiology explains the bleeding 1

Post-Treatment Follow-Up for Hematuria

If hematuria persists after successful treatment of the UTI (resolution of dysuria and frequency), then urologic evaluation becomes necessary. 1, 4 This would include:

• Repeat urinalysis to confirm persistent hematuria (≥3 RBCs/HPF) 4
• Cystoscopy if hematuria continues beyond 4 weeks post-treatment 1
• Upper tract imaging (CT urography) if indicated by risk stratification 4

Alternative: Symptomatic Treatment

For women with mild to moderate symptoms, symptomatic therapy with NSAIDs (such as ibuprofen) may be considered as an alternative to immediate antibiotics, with delayed antibiotic prescription if symptoms do not improve. 1 However, given the presence of gross hematuria, most clinicians would favor immediate antibiotic treatment to ensure rapid resolution. 1

Critical Pitfalls to Avoid

• Do not delay antibiotic treatment to obtain urine culture in straightforward uncomplicated cystitis—this adds unnecessary cost and delay. 2
• Do not assume the cold exposure is causative—it is coincidental; the infection is the primary issue. 1
• Do not order immediate cystoscopy or CT urography for hematuria occurring with acute cystitis symptoms—treat the infection first and reassess. 1, 4
• Do not use fluoroquinolones as first-line therapy—reserve these for complicated infections or pyelonephritis due to resistance concerns and adverse effects. 1

Expected Clinical Course

Symptoms should begin improving within 24-48 hours of antibiotic initiation, with complete resolution by day 3-5. 2 The median time to resolution of dysuria with appropriate antibiotics is 3 days. 5 If symptoms persist beyond 4 weeks or hematuria continues after other symptoms resolve, proceed with full urologic evaluation including cystoscopy and upper tract imaging. 1, 4